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FAMILY PLANNING FEE SCALE
<br />
<br />125% to 200% Federal Poverty NFP
<br /> Supplement
<br /> Patient fee category--Annual Gross Income
<br />
<br /> 150% SSBG*
<br />Family Reference (Title XX)
<br />Size Fi~ur.~ Eligibility 20%
<br />
<br />40% 60% 80%
<br />
<br />Full
<br />
<br />Pay
<br />
<br />1 $ 7,470 $0-$ 6,224 $ 6,225- 7
<br />2 $10,080 $0-$ 8,399 $ 8,400- 9
<br />3 $12,690 $0-$10,574 $10,575-12
<br />4 $15,300 $0-$12,749 $12,750-14
<br />5 $17,910 $0-$14,924 $14,925-17
<br />6 $20,520 $0-$17,099 $17,100-19
<br />7 $23,130 $0-$19,274 $19,275-22
<br />8 $25,740 $0-$21,449 $21,450-24
<br />9 $28,350 $0-$23,624 $23,625-27
<br />10 $30,960 $0-$25,799 $25,800-29
<br />11 $33,570 $0-$27,974 $27,975-32
<br />12 $36,180 $0-$30,149 $30,150-34
<br />
<br />,158
<br />,659
<br />,160
<br />,661
<br />,162
<br />,663
<br />,165
<br />,666
<br />,167
<br />,668
<br />,170
<br />,671
<br />
<br />$ 7,159- 8,092 $ 8,093- 9,026 $ 9,027- 9,959 $ 9,960
<br />$ 9,660-10,918 $10,919-12,180 $12,181-13,439 $13,440
<br />$12,161-13,746 $13,747-15,332 $15,333-16,919 $16,920
<br />$14,662-16,573 $16,574-18,485 $18,486-20,399 $20,400
<br />$17,163-19,400 $19,401-21,639 $21,640-23,879 $23,880
<br />$19,664-22,228 $22,229-24,793 $24,794-27,359 $27,360
<br />$22,166-25,056 $25,057-27,947 $27,948-30,839 $30,840
<br />$24,667-27,883 $27,884-31,100 $31,101-34,319 $34,320
<br />$27,168-30,710 $30,711-34,254 $34,255-37,799 $37,800
<br />$29,669-33,537 $33,538-37,407 $37,408-41,279 $41,280
<br />$32,171-36,366 $36,367-40,562 $40,563-44,759 $44,760
<br />$34,672-39,193 $39,194-43,715 $43,716-48,239 $48,240
<br />
<br />+ 2,610 + 2,175
<br />
<br />+ 3,480
<br />
<br />Natural Family Planning (NFP) Services' $8.00
<br />
<br />$16.00 $24.00 $32.00 $40.00
<br />
<br />'Natural Family Planning Services are those provided by a certified NFP Case Manager which are necessary to teach
<br /> effective method usage -- a typical "package" would include initial counseling and as many as three return sessions
<br /> spread over the next two to three months, as well as necessary NFP supplies (i.e., thermometers, charts, etc.)
<br /> Additional charges may be assessed (at the discretion of the Case Manager) for subsequent visits that exceed those
<br /> needed to establish basic NFP proficiency.
<br />
<br />*Social Services Block Grant
<br />
<br />-- Patients whose incomes fall into (or below) this range are not to be charged a fee.
<br /> The NFP Service package is not covered by existing reimbursement agreements -- do not
<br /> bill Title XX for NFP Services.
<br />
<br />
<br />
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